Notes
4 Building HIV/AIDS Competence in Ghana – Traditional Leadership and Shared Legitimacy: A Grassroots Community Intervention Best Practices Model
Donald I. Ray and Sherri A. Brown
I. INTRODUCTION
In 2006 the Joint Programme on HIV/AIDS of the United Nations (UNAIDS) and the World Health Organization (WHO) reported that there were estimated to be 38.6 million people living with HIV/AIDS (UNAIDS Report 2006, 8). Nearly 64 per cent lived in Sub-Saharan Africa (UNAIDS Report 2006, 15). HIV/AIDS has potentially devastating implications for developing countries and economies. All productive resources, human and capital, must therefore be mobilized in the fight against HIV/AIDS. Communities in developing countries that are profoundly affected by HIV/AIDS, such as Ghana, are increasingly exploring grassroots initiatives that address many of their educational, support, and resource needs. AIDS competence involves the notion that communities can become empowered to create and implement successful AIDS prevention and support programming and initiatives. Furthermore, AIDS competence arises from the actions that communities take to mitigate or alleviate risks to that community. As the case of Ghana will show, traditional leaders can play effective roles developing local AIDS competence through their involvement in mobilizing and delivering HIV/AIDS educational, support, and resource initiatives.
While African post-colonial states (known as “modern governments”) may appear to have a legal monopoly or ultimate power or sovereignty as expected by “Western” conceptions of what a state is, as well as having the capacity to carry out its powers, the reality is somewhat different and this needs to be examined in light of what needs to be done, and who has the capacity and competence to do this, in order to more effectively fight HIV/AIDS across Africa.
The main argument of this chapter is that because African chiefs (i.e., traditional leaders) have their own special historical and indigenous cultural sources of legitimacy or credibility, traditional leaders can play important roles in the development and implementation of HIV/AIDS policies and programs. Traditional leaders are part of the indigenous political and social structures that predate colonialism and the contemporary post-colonial state. In many African countries, governance is shared asymmetrically between the post-colonial state and traditional leaders because of the divided nature of legitimacy and sovereignty. Using the involvement of traditional leaders in Ghana in HIV/AIDS programs, the involvement of traditional leaders in the implementation of existing governmental and other-run development and HIV/AIDS programs could increase program success rates because traditional leaders could add their legitimacy or credibility in convincing their subjects of the usefulness of these programs. If traditional leaders are to play a more prominent role in the implementation of HIV/AIDS and development programs in Africa, first we need to confirm and analyze the actual participation of traditional leaders in HIV/AIDS programs. This chapter thus examines the participation and inclusion of traditional leaders in HIV/AIDS programming and policy apparatus in Ghana. This chapter demonstrates how traditional leaders in Ghana have contributed to the development of AIDS competence in local communities and thus serves as a grassroots community intervention best-practices model.
II. HIV/AIDS IN GHANA
In 2008 the Ghana Aids Commission summarized the volatility of the generalized epidemic in Ghana: though the prevalence rate in Ghana has remained below 5 per cent for over the past sixteen years, the number of persons living with HIV continues to rise daily (GAC 2008, 6). While in 2003 in Ghana, the adult (ages 15–49) HIV prevalence rate was 3.6 per cent, it declined to 2.7 per cent in 2005, but it increased in 2006 to 3.2 per cent.
In 2006 Ghana’s population was estimated to be 22,113,000 (UNAIDS 2006, 363). By 2007, an estimated 291,398 people (including 18,116 children) were living with HIV/AIDS. Furthermore, 170,000 children under 15 had lost one or both parents to AIDS by the end of 2006 (UNAIDS 2006). West Africa, including Ghana, has not escaped the impact of the HIV/AIDS pandemic and is in fact an area where opportunities for intervention for prevention of new infections may be successful in stemming the tide of the HIV epidemic. The active and growing presence of traditional leaders in social marketing campaigns against HIV/AIDS in Ghana suggests that the effectiveness of traditional authority in HIV/AIDS strategies deserves further investigation.
IMPACT OF HIV/AIDS
The HIV/AIDS pandemic has multidimensional and far-reaching implications. The epidemic has demographic, political, security, economic, social, and cultural implications. Demographically, HIV/AIDS is contributing to a reversal of age-specific mortality patterns, with increasing proportions of younger people dying. With increased adult mortality due to AIDS, societies have witnessed the creation of child-headed, elderly-headed, single-parent, and over-extended families. Moreover, there have been increased instances of cluster foster care homes (housing one or more AIDS orphans), itinerant and homeless children and gang families in severely affected areas. The numbers of AIDS orphans in developing areas are growing. In addition to the concerns of how to care for and support these orphans is the question of how these children will affect social stability in the future.
The impact of HIV/AIDS on individuals and households will be felt earlier and will vary according to existing resources of capacities they are able to draw upon. Thus, individuals, especially those with full-blown AIDS will experience immediate impacts on their health status via their experience with increases in morbidity and illness. These immediate impacts on health may have adverse implications on their social and economic productivity and participation. Thus effects on an individual will ultimately create effects on their families, households, and communities, as a previously productive individual becomes semi or non-productive and requires care and support from their household and community (Barnett and Whiteside 2002). When individuals affected with or by HIV/AIDS change their social and economic patterns of consumption, production, and participation, this creates effects for agriculture, business, government, and civil society. Thus, aggregate individual impacts from HIV/AIDS bear profound and often difficult to measure impacts for multiple levels and sectors.
Furthermore, because the HIV/AIDS pandemic disproportionately affects sub-Saharan Africa, it is largely developing countries that must contend with this devastating epidemic. While they struggle to develop, HIV/AIDS threatens to undermine or destroy their efforts. Ultimately, HIV/AIDS is expected to exacerbate existing social, political, and economic issues and inequities. Because of the multidimensional impact and expression of disease, HIV/AIDS is expected to have profound and complex implications for human health and well-being that goes well beyond its immediate clinical impact.
The HIV/AIDS pandemic requires a strong and collective global response. Globally, political commitment has grown stronger, grassroots mobilization is becoming more dynamic, funding is increasing, treatment programs are being developed and initiated, and prevention efforts are increasing; however, the global response must be intensified in order to provide the necessary resources and commitment that are required to prevent new infections and to care for those currently living with HIV/AIDS. All productive resources, human and capital, must be mobilized in the fight against HIV/AIDS. As the case of Ghana shows, traditional leaders can play effective roles in this fight.
III. TRADITIONAL AUTHORITY AND DIVIDED LEGITIMACY IN PRE-COLONIAL, COLONIAL, AND POST-COLONIAL STATES: BUILDING ON GRASSROOTS GOVERNANCE
Traditional leaders are known in English as chiefs, traditional authorities, traditional rulers, monarchs, kings, nobles, aristocrats, and natural rulers in a variety of African and other countries. Traditional leadership is meant to include those political, socio-political, and politico-religious structures that are rooted in the pre-colonial period rather than in the creations of the colonial and post-colonial states. By this key consideration, traditional leaders can include kings, other aristocrats holding offices, heads of extended families, and office-holders in decentralized polities, as long as their offices are rooted in pre-colonial states and other political entities. If the office is purely a creation of the colonial or post-colonial states but still involves indigenous peoples, the office should be called “neo-traditional.”
The division of the chronology of African political organization into three periods (pre-colonial, colonial, and post-colonial) is well accepted but should not be seen as applicable only to Africa. The trilogy of pre-colonial state, colonial state, and post-colonial state applies to any contemporary state in Africa, Asia, the Americas, or elsewhere that was the product of the imposition of European imperialism and colonialism since the expansion of capitalism out of Europe from the 1400s onwards. However, one might characterize the pre-colonial states and other pre-colonial political entities as being rooted in political legitimacies that were particular to their special histories, which existed before these pre-colonial states and other polities were absorbed one way or another by European empires. Such absorption involved the creation of colonial states by which the European empires ruled their newly subjugated and/or subordinated colonies into which the various pre-colonial states and polities were drawn. These pre-colonial states and other polities were then processed into various components of the colonial states. In many cases, the indigenous peoples had their political leadership turned into instruments of colonial rule for the benefit of the empires, but the empires were not strong enough to eliminate completely all elements or traces of this pre-colonial heritage: “kings” became “chiefs” in the lexicon of imperialism and colonialism. While the colonial state intended to indicate the subordinated status of the former pre-colonial leader by this linguistic trick, ironically the real pre-colonial terms of the “chiefs” survived in their own languages. Even more ironically for colonialism, often these “chiefs” or “traditional leaders” became rallying points of resistance to colonialism and sources of cultural pride to those indigenous peoples who had been colonized. Where traditional leaders/chiefs thus survived into the periods of the colonial state and the post-colonial state, they often retained sources of political legitimacy rooted in the pre-colonial period, which were unavailable to the colonial state because it had been forced on the indigenous people.
Political legitimacy deals with the reasons that people are expected to obey political authority, especially that of government. Baynes (1993) argues that political legitimacy is an important mechanism of the state to obtain the compliance of its citizens (or subjects) with the laws (or other wishes) of the state. Traditional authorities have specific and distinct claims to legitimacy that are recognized by their subjects. Traditional authorities can claim special legitimacy in the eyes of their people because these institutions are seen as embodying their people’s history, culture, laws and values, religion, and even remnants of pre-colonial sovereignty.
The colonial states and the post-colonial states draw upon different roots of legitimacy and sovereignty than those of the pre-colonial states. Looked at in the brilliant light of democracy, the colonial state would have to admit that its claims to sovereignty were based in the main on violence, racism, and diplomatic trickery, and that its claims to legitimacy as to why the indigenous people should obey its dictates were usually based on: (1) rights of the conqueror rather than the consent of the people, (2) assertions of culture or racial superiority of the colonizers over the indigenous people, and (3) the use of a constitutional and legal order based on or rooted in the imperial power. For these and other reasons, the colonial state was unable to take over the legitimacy base of the pre-colonial period: to do so would be to call into question its own legitimacy.
The post-colonial state is in a more ambiguous position with regard to the pre-colonial period and to traditional leaders than is the colonial state. Although the post-colonial state has often had its constitutional and legal legitimacy rooted in the colonial state, especially when there was a peaceful handover of power from the colonial state to the post-colonial state, the post-colonial state can claim its legitimacy from the additional roots of (1) the nationalist struggle for independence by the people, and (2) the expression of the democratic will of the people through elections and other political processes and, eventually, a legal-constitutional system that has been processed, re-validated and created by the institutions created by the post-colonial state which express the democratic will of the people. However, the legitimacy of traditional leadership/chieftaincy institutions remains, in nearly all cases beyond the grasp of the post-colonial state, precisely because chieftaincy legitimacy is rooted in the pre-colonial period and there has been a fundamental rupture in the political fabric caused by the imposition of colonialism. Thus a people may choose to express themselves politically for many policy areas through the legislative, executive, and judicial institutions of the post-colonial state, but also decide that certain policy matters (e.g., custom, land, other local matters) are best expressed by their traditional leaders. Thus, because the people of a post-colonial state recognize that the roots of political legitimacy are divided between the post-colonial state and the traditional (i.e., pre-colonially rooted) leadership, these peoples may well decide that their democratic practice includes aspects of both the post-colonial state and traditional leadership. This then would lead to a situation in which the division of the different roots of legitimacy would create a shared legitimacy as the traditional authorities and the post-colonial state pool their legitimacy to promote more and better development, especially more effective responses to HIV/AIDS.1
Traditional leaders have long been recognized by the colonial and post-colonial states as being important to the processes of rural local government in Ghana. In both the colonial and post-colonial states, traditional leaders have been incorporated directly into local government and local governance, albeit in various formats. The advent of the National and Regional Houses of Chiefs has institutionalized and entrenched important political functions for traditional leaders. The National House of Chiefs has fifty members, comprised of five members from each of the ten Regional Houses of Chiefs. There are ten regional houses of chiefs and one hundred and sixty traditional councils (Ray 2003a; 2003b). While they were initially perceived as “auxiliaries” or “subordinate allies” in colonial rule, traditional leaders are now occupying different roles in the Ghanaian contemporary post-colonial state. Christiane Owusu-Sarpong (2003) suggests that traditional leaders function as “intermediaries” between ministries, parliament, and the people. Ray (2003a) suggests that traditional leaders may contribute to the “legitimacy pool” of the contemporary post-colonial state. Hence, both Owusu-Sarpong (2003) and Ray (2003a) concur, not only that traditional leaders possess their own unique sources of political authority, but also that the exercise and cooperation of this authority in conjunction with the post-colonial state is necessary for the achievement of development goals. Owusu-Sarpong (2003) argues that their legitimacy may be “added” to the post-colonial state’s legitimacy resources and that they may indeed serve as a necessary condition to certain governmental actions and activities. She argues that no decision taken at the level of central government, and directly concerning the people in matters such as communal health, education, use and distribution of land, gender issues, etc., can easily be implemented without the active involvement of the traditional authorities in the various regions.
Chiefs in Ghana are influential with their subjects in terms of their abilities to mobilize their people for development, in their articulation of their sense of public morality, and their influence in shaping public opinion. Thus, traditional leaders in Ghana can potentially exert significant influence within their communities. Owusu-Sarpong (2003) argues that chiefs are active opinion leaders, and she cites their presence in media sources and official and informal gatherings as evidence that their opinions and activities are considered important. Moreover, as active opinion leaders, traditional leaders have the potential to be important sources of public education on many social issues. Given their position within a community, traditional leaders can effectively transmit important social messages and values that contribute to development goals. For instance, if traditional leaders impart positive messages and strategies for HIV/AIDS, gender empowerment, environmental stewardship, and cultural and heritage preservation, this is likely to both persuade and mobilize people to alter their behaviours in ways that produce a more positive and supportive social and cultural environment.
Furthermore, empowering and encouraging female traditional authorities to act as moral and opinion leaders for important social issues helps women and girls in rural and urban communities to access and alter behaviours. In Ghana, queenmothers advise chiefs and serve as moral leaders of the community (Ray 2003b, 25). For instance, Nana Boatema-Afrakoma II, queenmother of Juansua, is the Juansua chief’s major councillor and is very influential in the selection of new a chief or in his impeachment. Her traditional responsibilities relate to the role of women in society and the moral education of the young girls in society. Accordingly, she has organized workshops for queenmothers on various issues affecting her people and believes they need to reflect on the conditions prevailing in their communities and find ways of introducing changes that will promote development (Owusu-Sarpong 2003, 60). Thus, traditional authorities have the potential to influence and create important social and behavioural changes that will promote development goals, including those of fighting HIV/AIDS, within their communities and Ghana.
Traditional leadership is a factor that has been significantly overlooked in the evaluations of government and governance in much of contemporary Ssub-Saharan Africa and even in parts of the Afro-Caribbean (Zips 2003; Pakosie 1996). This oversight continues to result in lost opportunities, especially with regard to anti-HIV/AIDS strategies, in terms of both development and understanding. Accordingly, we need to consider what role traditional leaders might play in the struggle against HIV/AIDS. The fight against HIV/AIDS requires the mobilization of all available and credible resources and actors. Given their special legitimacy and credibility, traditional authorities may be able to play an important role by pooling their legitimacy or credibility with government and others to build AIDS competent communities by strengthening and facilitating social marketing campaigns, fostering positive and supportive environments for people living with HIV/AIDS and affected by HIV/AIDS, and mobilizing community resources and participation in the fight against HIV/AIDS.
IV. GHANA’S POLICY FRAMEWORK FOR HIV/AIDS
In response to the spread of HIV/AIDS in Ghana, the Ghana HIV/AIDS Strategic Framework (Government of Ghana 2001) outlined Ghana’s strategy for 2001–2005. A multisectoral team including the National Population Council, National Development Planning Commission, Ministry of Health, the former Ministry of Employment and Social Welfare (now Ministry of Manpower Development and Employment), the private sector and NGOs with input from regional and district level officials developed the Ghana HIV/AIDS National Strategic Framework (NSFI). The preface of Ghana’s strategic framework states that HIV/AIDS “requires a holistic multisectoral and multidisciplinary response to confront it and bring it under control.” Consequently, the framework embodied these principles by identifying and employing multiple partners and sectors in the fight against HIV/AIDS in Ghana. Of special interest to our analysis are those parts of the framework dealing with traditional leaders.
The 2001–2005 framework identified five priority action areas: 1) prevention of new transmission, 2) care and support for people living with HIV/AIDS, 3) creating an enabling environment, 4) decentralized implementation and institutional arrangements, and 5) research, monitoring, and evaluation of existing trends and programs. The framework served to address and outline the goals, guiding principles, and strategies for the prevention of HIV transmission, the provision of care and support for people living with HIV/AIDS and people affected by HIV/AIDS, and the creation of a supportive and empowering legal and ethical environment.
Ghana’s first HIV/AIDS strategic framework recognizes traditional authorities as a key sector for program targeting and implementation. Traditional authorities are thus expected to receive and transmit policy strategies within their communities. The strategic framework regards the participation of traditional authorities as integral to the implementation and realization of their policy strategies and objectives.
Most importantly, the framework recognized that these key strategies will require the involvement and participation of selected groups and organizations. The framework identifies key sectors, settings, and population groups (providers/patients/audience) in the implementation or targeting of these three key prevention strategies. Traditional authorities were identified as a key sector in both the targeting and implementation of policy strategies. Thus, traditional authorities were recognized as requiring education on prevention strategies and behaviours and were seen as potential facilitators and implementers of policy strategies as they relate to the prevention of HIV transmission.
The second priority action area of the framework is the provision of care and support for people living with HIV/AIDS and people affected by HIV/AIDS. The framework discussed two major strategies to intensify and implement strategies for providing care and support to these individuals and groups: providing and strengthening institutional care for people living with HIV/AIDS, as well as providing and strengthening home care support for people living with HIV/AIDS. Accordingly, the framework discusses the need to mobilize funds for institutional and home care support, HIV/AIDS orphans, build the capacity of community networks such as church-based organizations, faith-based organizations and community volunteers in caring and supporting people living with HIV or AIDS (PLWHA) and people affected by HIV/AIDS. The 2001–2005 framework considered traditional authorities as a key sector in Ghana’s implementation strategies and objectives.
The fourth priority action area called for the creation of a supportive, legal, ethical policy environment for HIV/AIDS programs. The framework identified three major strategies for this policy objective: a) improving the knowledge of the general public on HIV/AIDS and the rights of PLWHA; b) promoting non-discriminatory policies and practices at workplaces, service delivery points, in communities and in families; and c) programs for sex workers. The framework indicated that Ghana needed to develop a rights-based approach to HIV/AIDS, and thus needed to formulate a legally binding foundation for dealing with procedural, institutional, and other accountability mechanisms related to HIV/AIDS in society. Again, traditional leaders were identified as key implementers.
The 2001–2005 framework’s coordination and implementation approaches acknowledged the importance of articulating viable implementation arrangements and the need to mainstream HIV/AIDS into sectors and programs. Furthermore, non-government sectors such as traditional leaders, private-sector organizations, NGOs, community-based organizations (CBOs), religious institutions, professional bodies and associations, youth groups, etc., were to develop and implement programs in accordance with priorities and intervention strategies outlined in the framework. At the district level, committees on AIDS bringing together local government and non-government actors were to be established to co-ordinate, monitor, and supervise all HIV/AIDS activities. The District HIV/AIDS Committee included all bodies and people concerned with fighting AIDS, such as chiefs, NGOs, religious bodies, youth and women’s associations, private sector institutions, people living with HIV/AIDS, and other individuals who were competent in developmental issues.
At the national level, Ghana’s strategic framework recognized traditional authorities as a key sector in both program targeting and implementation. At the district level, traditional authorities were to be involved in and represented on HIV/AIDS committees. At the local level, traditional leaders were to be involved in joint and multisectoral social marketing campaigns against HIV/AIDS. Their involvement included acting as directors, spokespersons, intermediaries, and advisers for HIV awareness and education campaigns and providing supports for people living with HIV/AIDS and persons affected by HIV/AIDS.
The Ghana AIDS Commission’s second national strategic framework (GAC, NSFII, 2006–2010) continued to integrate traditional leaders into Ghana’s strategy. In terms of the enabling environment for the fight against HIV/AIDS, traditional leaders were seen as one of Ghana’s core “socio-political structures,” one that has “the potential for effective social mobilization to combat HIV/AIDS at the community level” (GAC, NSFII 2006, 24). The contributions of the chiefs and queen mothers/queens was recognized but the Ghana AIDS Commission argued that “the full potential of traditional leaders as strong advocates has not been sufficiently utilized. Community responses must actively involve chiefs, queens and traditional councils to increase participation of traditional leaders and ensure community ownership of the response” (GAC, NSFII, 2006, 34).
V. SOCIAL MARKETING, TRADITIONAL AUTHORITIES AND HIV/AIDS PREVENTION AND SUPPORT PROGRAMMING
Social marketing has been defined as the “design, implementation and control of programs calculated to influence the acceptability of social ideas” (Kotler and Zaltman 1971, 5). Social marketing applies commercial marketing principles to social problems and objectives. (AIDS Calgary workshop on Social Marketing for Health, Calgary, 13 June 2003). Social marketing has its roots in religion, politics, and education, and its intellectual roots are found in the disciplines of psychology, sociology, political science, communication theory, and anthropology. Fundamentally, social marketing is about capturing audience attention through planned and creative communication strategies. Social marketing is distinguished from commercial marketing by its emphasis on non-tangible products, such as ideas and practices. Its purpose is to positively influence the voluntary behaviour of a target audience and therefore improve their personal welfare and that of the society. Governments and multilateral organizations are increasingly employing social marketing strategies as an effective means of addressing serious health issues in developing countries. Successful social marketing programs improve the health of people by promoting healthy behaviour, ensuring the availability of health products and services, and motivating and educating people to use them (“Social Marketing”; http://www.gsmf.com.gh/strategy/social.htm).
In sub-Saharan Africa by 2001, twenty-four countries had HIV prevalence rates over 5 per cent (Kumaranayake and Watts 2001, 541). Many countries in Africa are demonstrating increasing rates of HIV prevalence. With no cure or vaccine in sight, HIV prevention efforts must be a top priority. In order to educate Africans on HIV/AIDS, creative and effective social marketing strategies and campaigns are imperative if we hope to slow the spread of HIV/AIDS, reduce the rate of new infections, and provide caring and supportive environments for those currently living with HIV/AIDS.
Social Marketing and AIDS Competence
AIDS competence has been defined as:
... the ability of people to maintain and improve the quality of their lives by facing up to HIV and AIDS. They determine and manage their own responses to the HIV/AIDS epidemic in their own community by assessing accurately the factors that make them vulnerable to, or put them at risk of infection with, HIV. They act so as to reduce their vulnerability and those risks, and they mobilize adequate holistic care and support when infected with, or affected by HIV/AIDS (Lamboray and Skevington 2001, 514).
AIDS competence means that communities become empowered to create and implement successful AIDS prevention and support programming and initiatives. AIDS competence arises from the actions that communities take to mitigate or alleviate risks to that community (Lamboray and Skevington 2001, 514). AIDS competence involves grassroots movements and campaigns whose objective is behavioural change in regards to both sexual behaviour (HIV prevention) and social behaviours (de-stigmatization) (Lamboray and Skevington 2001, 516–18).
When traditional authorities are mobilized and integrated into the fight against HIV/AIDS, they can become powerful agents in the development of AIDS competent communities. They can act as influential intermediaries for HIV/AIDS social marketing campaigns led by individuals or groups within the community or can serve as campaign leaders and spokespersons. Traditional leaders may also help to build AIDS competence by identifying potentially harmful social and customary practices that constitute a hindrance to anti-HIV/AIDS efforts. Traditional leaders can also help to mobilize community resources and participation for the care and support of people living with or affected by HIV/AIDS. Given their position within their communities, traditional authorities have the potential to be powerful and persuasive agents for social and behavioural change.
SOCIAL MARKETING AND TRADITIONAL AUTHORITIES
In Ghana, traditional leaders have actively engaged in the fight against HIV/AIDS in several capacities. Given their legitimacy and credibility amongst their subjects, they are well positioned to play effective roles in HIV prevention and support within their communities. President John Kufuor suggested that traditional leaders could serve as “instruments of socio-political cohesion to facilitate national development” (“Chiefs must be instruments of social-political cohesion”; http://www.mclglobal.com/History/Jan2003/07a2003/07a3n.html).
Traditional leaders in Ghana have demonstrated their commitment to fulfilling this role and extending this to HIV prevention and support through their participation in various activities and campaigns. They are increasingly serving as collaborative and informed partners in the fight against HIV/AIDS. They are functioning as advisers, intermediaries, and educators in HIV/AIDS education, prevention, and support programming in their communities and traditional areas. They can also play important roles in fighting stigmatization against people living with HIV/AIDS by fostering the development of supportive and informed communities. The Omanhene of the Manso-Nkwanta traditional area in the Amansi West district said that stigmatization is one of the most problematic aspects in the fight against HIV/AIDS and has consistently appealed to his people to create a climate of acceptance and support for those living with HIV/AIDS (“Omanhene donates computer for HIV/AIDS data processing,” [on-line], 8 June 2003). Traditional leaders can also play a role by identifying social or cultural practices that may contribute to the spread of HIV/AIDS (i.e., tattooing, puberty rites, love covenants). Susan Osam, a reproductive rights/health expert of the United Nations System Gender Programme has called on chiefs and queenmothers to reflect on social and cultural practices that may be problematic in the fight against HIV/AIDS in their communities (“Chiefs/Queenmothers attend AIDS Workshop,” [on-line], 17 September 2003). Traditional leaders can play an important role by reviewing social and cultural practices in their communities with a view to identifying practices that may be harmful or potentially expose people to HIV infection and subsequently identify safer solutions or alternatives.
Traditional leaders have an important role to play in HIV/AIDS education and prevention in their communities. Many traditional leaders have either developed HIV/AIDS awareness and prevention programs or act as spokespersons, advisers, or intermediaries for prevention programs. For example, the paramount chief of the New Juaben Traditional Area, Daasebre, Dr. Oti Boateng donated a 7-million-cedi computer to the New Juaben Traditional Council in support of its anti-HIV/AIDS program launched at Koforidua on 6 June 2003. The collaborative campaign, “Coalition of Life Preservers” involves eighteen civil society organizations, including the New Juaben Traditional Council. The program includes roundtable discussions attended by chiefs, queenmothers, and headmasters of schools in the Ada and Akwadum circuits in the Koforidua municipality (“Omanhene donates computer for HIV/AIDS data processing,” 8 June 2003). Osagyefo Agyemang Badu (Dormaahene) advised chiefs in his area to educate the youth on HIV/AIDS and cited HIV/AIDS as a major threat for future generations (“Dormaahene warns chieftaincy contractors,” 3 November 1999). In the Tapa traditional area, traditional leaders have partnered with Freedom International, an NGO, in developing an HIV/AIDS education campaign (“NGO and Chiefs Launch HIV/AIDS Education Campaign,” 2 September 2003).
The Okyenhene, Osagyefuo Amotia Ofori Panin (King of Akyem Abuakwa in Ghana) has had an enormous impact on HIV prevention, education, de-stigmatization, research, and support in his traditional area. In May 2002, his Traditional Council launched an HIV/AIDS research centre. He has also participated in numerous public events for HIV/AIDS awareness, including in 2002 leading a large number of members of keep-fit clubs from Accra, children and individuals from Okyenman in a twelve-kilometre run to mark the second Okyenman HIV/AIDS day celebrations. The year before, at the first HIV/AIDS day celebrations, the Okyenhene was publicly tested for HIV (Interview, 13 October 2002). At this race, the Okyenhene urged people to discard the notion that the disease is caused by witchcraft. The Okyenhene has shown that in the fight against HIV/AIDS, superstitions and customary taboos must be examined for both their impact on stigmatization of persons living with HIV/AIDS, as well as for their potential to elevate risk of transmission of HIV. He publicly appealed to citizens of Akyem Abuakwa to help eradicate poverty and ignorance in rural communities in the traditional area. He made the appeal when he briefed the Second Session of the Akyem Abuakwa Traditional Council on his tour of the 160 towns and villages in the traditional area (“Okyenhene Appeals to Successful Akyems,” [on-line], 30 May 2001). The Okyenhene offers an excellent example of how traditional leaders can play effective and important roles in HIV/AIDS education, prevention, destigmatization, and support within their communities.
Traditional leaders have also been encouraging schools, families, and community groups to include HIV/AIDS education in their homes and curriculum. Nana Bi-Kusi Appiah II, Omanhene of the Manso-Nkwanta Traditional Area in the Amansi West district, appealed to parents to invest in the education of their children, particularly the girls, to prevent them from engaging in early sex. Nana Frempongmaa II, Dwantuahemaa (one of the queenmothers of the Dormaa traditional area) said traditional rulers in the country have a major role to play in the AIDS campaign. She articulated that she “strongly believe(s) that we must inculcate HIV/AIDS education into the school curriculum” (“Queenmother blames media,” [on-line], 4 March 2002). Mobilizing the support and involvement of traditional leaders in HIV/AIDS education and prevention increases the effectiveness of such programming and thus can mitigate the impact and progression of HIV/AIDS in their communities. She noted that:
When a traditional ruler talks people listen. He gets the audience. His people are in love with him, so whenever he advises the children, they take it. It is not just about advising but about the ruler leading a life that makes his subjects know that he has the commitment at heart. (“Queenmother Blames Media,” 4 March 2002)
Traditional leaders have special sources of legitimacy and credibility within their communities and their subjects closely regard their actions and activities. Accordingly, their mobilization can enhance and complement the efforts of government and others and ultimately build AIDS competent communities.
THE CASE OF THE MANYA KROBO QUEENMOTHERS ASSOCIATION (MKQMA)2
The history of the offices of the king, queenmothers, and other chiefs amongst the Krobo people is rooted in the pre-colonial period. When Manya Krobo, which is to the east and north of Accra, came under the control of the British colonial state, the pre-colonial or traditional offices were subordinated to it and were transformed and renamed in English as chieftaincy offices. The konor had been considered by his pre-colonial state as being the king of Manya Krobo but was considered by the British colonial state to be a “paramount chief,” i.e., a superior chief to whom other chiefs owed allegiance.3
After independence in 1957, the post-colonial state created the Regional Houses of Chiefs and in 1971 created a National House of Chiefs. While the title “paramount chief” continued to be recognized by the post-colonial state, the use of the English-language title, “king” and terms such as “His Majesty” have been noticeably used by the kings themselves who continue to use their indigenous, traditional titles as well. In the case of the present (1998–) konor or king of Manya Krobo uses the title, His Majesty Nene Sakite II. The female traditional leaders went through a similar transition in states and the title used today, “queen-mother” (also spelled “queen-mother” or “queen mother”) is used in the English language and in the Fourth Republic’s constitution to mean a female chief. (It should be noted that the term “queenmother” is not used for a woman who occupies a traditional office that is nearly always held by a man.)
The Manya Krobo queenmothers created the Manya Krobo Queen-mothers Association (MKQMA) in 1988. An association of queenmothers is a form of organization that combines individual traditional offices in a new manner, even while it continues to recognize the traditional hierarchy in certain ways – e.g., the paramount queenmother is the president of the Manya Krobo Queenmothers Association. Three hundred and seventy-one queenmothers of various ranks form the membership of the Manya Krobo Queenmothers Association. They are drawn from all six divisions of the Manya Krobo Traditional Area.4
The Manya Krobo paramount queenmother, Manye Mamle Okleyo, is the president of the Manya Krobo Queenmothers Association. The program manager of the MKQMA is Manye Seyelor Natekie I, who is also the deputy to the paramount queenmother.
The MKQMA was one of a number of district and regional associations of queenmothers that were established in the 1980s and 1990s to address the potential that women traditional leaders were believed to have for the promotion of development, especially for women and children in their communities. In the case of the Manya Krobo Queenmothers Association, the queenmothers noticed an increase in the number of orphans for whom the queenmothers were traditionally expected to arrange fostering. Furthermore, the queenmothers noticed that these orphans were far more difficult to place with what should have been their natural extended family, which appeared to have somehow broken down. In the queenmothers’ discussions with each other and other members of the Manya Krobo community, one of the district health officers noted that cases of young mothers dying from HIV/AIDS were beginning to be seen. The queenmothers, educators, and health officials arrived at a joint analysis that suggested that HIV/AIDS was now significantly present in their community and that the orphans were the children of community members who had died from HIV/AIDS. The queenmothers, the health officers, and others faced several questions of how to respond to the presence of HIV/AIDS in their community. What should be done? Who should do it? From where would the resources come? Since the primary method of transmission of HIV/AIDS in Ghana is heterosexual transmission, how could this be discussed in public? Was this not a source of shame for the community? Should the community therefore just be silent over the issue?
As these discussions progressed, the queenmothers decided, with the medical advice of the government medical officers and Family Health International (of the United States), that their traditional responsibilities to the community would entitle them to play a leading role in their community’s responses to the newly discovered presence of HIV/AIDS in their community. First, as queenmothers, they had their responsibilities to the Manya Krobo girls and young women in educating them for the Dipo ceremonies that marked their recognition as adult women of the community. The queenmothers decided to extend this education to include questions concerning how to prevent exposure to HIV or how to deal with it after infection. Second, since queenmothers had customarily played a role in fostering the community’s orphans, it would be very natural for the queenmothers to organize community responses to the growing number of HIV/AIDS orphans. The queenmothers decided that they would organize their actions through the previously organized Manya Krobo Queenmothers Association. In short, the queenmothers, with the agreement and support of the konor (king) of Manya Krobo, the government and NGO medical officials, and many in the community, decided to use their traditionally rooted legitimacy to act for the health, protection and development of their grassroots community. The Manya Krobo Queen-mothers Association strategy has been composed of four main tasks: social marketing/public education; income-generation for young women; support for people, directly or indirectly, living with HIV/AIDS; and mobilizing resources for the community to increase their AIDS-fighting capacity. Ultimately, the activities of the Manya Krobo Queenmothers Association have helped to build an AIDS-competent community.
The Manya Krobo Queenmothers Association worked to build AIDS competence at the grassroots level in addition to the AIDS competence that already existed in local medical facilities such as the two local hospitals. The queenmothers themselves needed to be educated in HIV/AIDS, its transmission, existing strategies to prevent its spread to more people, and what strategies and resources are available to deal medically and socially with people who have contracted HIV/AIDS. They negotiated with local medical facilities, such as the hospital and medical officers of the Ministry of Health and other bodies such as the Ghana AIDS Commission as well as international NGOs present in Ghana, such as Family Health International (www.fhi.org). These bodies provided expertise and other resources that have allowed the queenmothers to be trained to have the technical competence that would allow them to conduct social marketing/public education campaigns in their sub-communities of Manya Krobo. These AIDS competence-building actions in the community resulted in increasing the number of people with knowledge of HIV/AIDS, as well as increasing the amount of knowledge that they had. In short, a corps of non-medical people in Manya Krobo who could act as trainers and actors in social marketing campaigns was created. The queenmothers’ actions also brought in the additional competence and resources of such key bodies as Family Health International and the Ghana AIDS Commission.
As the queenmothers began to build AIDS competence within their community, they expanded the scope and nature of their public education activities into social marketing programs against HIV/AIDS. Whereas at the start, a queenmother would have warned in general of the dangers of HIV/AIDS to a community gathering, as the social marketing programs of the MKQMA developed, the queenmothers talked to their communities as part of coordinated programs with specific social marketing messages to be conveyed. The MKQMA focused their social marketing campaigns on female children and women, groups who had been identified as being at risk to HIV infection; these foci reflected the traditionally defined, endorsed, and expected activities of queenmothers.5
One of the traditional ceremonies that Manya Krobo queenmothers supervise is Dipo. Dipo marks the transition from being a female child to being recognized as an adult woman. Before the ceremony begins, there is a period of education for each group of girls as to Krobo society’s expectations of them as women. The MKQMA made or is trying to make several changes to the ceremony. First, the queenmothers have added in a new section on HIV/AIDS during the education sessions in order to alert the girls to new sexual issues that they will confront as women. Second, the queenmothers have adopted the slogan and practice of “one initiate, one razor blade.” In the past, many girls might have their hair shaved by an initiator using the same razor blade. However, now in the age of HIV/AIDS, the sharing of a blade that could potentially transmit HIV is problematic to say the least. Third, the MKQMA have been attempting to raise the age at which girls become women so as to delay the onset of societal-sanctioned sexual activity through marriage.
Besides the Dipo ceremony, the queenmothers built upon their traditional functions of calling together a number of girls and young women to discuss societal morals, etc., by adding topics drawn from HIV/AIDS resources and presenting them to young girls, women, and others in culturally appropriate terms. For example, the type of cloth that is worn by chiefs on official duty can send a message to their communities. The MKQMA members have adopted the wearing of a special blue batik cloth when they are on some official AIDS duties. As this is broadly known throughout their communities, the wearing of this cloth by the queenmother sends a clear social marketing message to those who see them and to the girls and young women who take part in the educational discussions with the queenmothers. The MKQMA with Family Health International (and USAID funding) and the Ministry of Health developed a book-sized tento-twelve-page flip chart to be used by the queenmothers in their social marketing discussions with girls and young women. On one side, there is a colour photograph of a dramatized situation that could lead the depicted young women to be exposed to HIV by getting involved in sexual activity. On the other side of the laminated page, there are a series of questions in English and Krobo (to serve those wishing to speak one language or the other). The queenmother shows the picture to the young women and leads them through the questions so that the young women can perceive how certain unfamiliar situations can cause exposure to HIV. Another example is the docudrama video that the MKQMA developed with the support of Family Health International, USAID, and the Ministry of Health. This video dramatizes how young women can become infected with HIV and the subsequent stigmatization that they may suffer. The video shows the MKQMA intervening successfully on behalf of the newly HIV-positive young woman by utilizing several social marketing messages.
The MKQMA formed a “Smart Ladies Association” for young women in which they received education on HIV/AIDS as well as mentoring and training from the queenmothers. The MKQMA members have also formed a choir so that they can use music to deliver HIV/AIDS social marketing messages. They have composed a number of HIV/AIDS songs in Krobo, one of which ends with the words (English translation): “If you can’t control yourself, at least use a condom.” This reflects one of the main social marketing messages of the Ghana AIDS Commission of ABC: Abstain, Be Faithful, or use a Condom.
Income generation was the third major task that the Manya Krobo Queenmothers Association faced in the implementation of their strategy to fight HIV/AIDS in their community. The queenmothers needed to create employment for at least some of the young women who were at risk because of economic factors. Such young women also were part of the traditional mandate of the offices of the queenmothers. The Krobo area is known for its beautiful multi-coloured beads. Traditional leaders wear these beads, often large in size, as part of their regalia. There is some cultural tourism in Ghana and in Krobo relating to the selling of these beads. As part of the MKQMA’s project, young women have been hired to string the beads into necklaces and bracelets. These are then sold through a variety of networks, mainly in Ghana, but reaching as far as Calgary, Alberta, Canada. Young women at the project also make batik cloth, which is sold as wraps, or it may be sewn into shirts, dresses, etc. This is the cloth that the queenmothers wear on their official anti-HIV/AIDS duties. The project also makes soap in order to generate income for the young women.
Providing support for the Manya Krobo people living with HIV/AIDS is the fourth major task of the MKQMA’s strategy. For the adults living with HIV/AIDS, the main activity of the MKQMA has been carrying out the 2002 (and other) anti-stigmatization campaigns of the Ghana AIDS Commission. Perhaps, in part as a result of all the AIDS competence and social marketing work done by the MKQMA in their area, St. Martin’s Hospital, which had conducted an initial pilot project with anti-retroviral drug therapies in their area, was one of only three hospitals in Ghana chosen to administer an expanded pilot project in the distribution of anti-retroviral drugs to 2000 people for two years starting in January 2004. Providing support for the AIDS orphans is a major part of the MKQMA. There were some 586–660 male and female children of Manya Krobo women who have died of HIV/AIDS. The MKQMA attempts to provide food, clothing, and other subsistence to the AIDS orphans. The Ghana AIDS Commission has been providing this for 120 orphans, but the MKQMA are continually searching for new support, some of which has come from as far away as Calgary, Canada. For example, presentations of Prof. D.I. Ray, based on his International Development Research Centre (IDRC) funded research to Calgary groups such as the Women’s Network on HIV/AIDS and the University of Calgary students’ group, the Global AIDS Awareness Group (GAAG) led the groups to donate funds for the support and education of the AIDS orphans sponsored by the MKQMA. Funding is required in order to pay the extra fees for schooling for the AIDS orphans. For example, money is needed to provide for school supplies such as exercise books, the special costs of exams and lessons, etc. Such education costs range from CDN$5 to $20 per year.
Mobilizing resources for the community in order to increase their AIDS-fighting capacity is the fifth major task of the MKQMA strategy. The queenmothers acted as resource mobilizers by organizing their HIV/AIDS program in formats that were acceptable to those non-traditional authority organizers that could provide resources of funds and expertise. The queenmothers acted as mediators and facilitators between those needing the resources (the local community) and those with the resources (Ghana government, diplomats, NGOs, and Community Based Organizations) outside the community such as Family Health International and USAID, and internationally based groups such as the International Development Research Centre of Canada-funded research project,6 the Traditional Authority Applied Research Network (TAARN). TAARN’s IDRC-funded research led to students at the University of Calgary’s Global AIDS Awareness Group raising funds for the MKQMA AIDS Project. One student, Ms. Kim Schoon, travelled to Ghana, met with the MKQMA, and was made an honorary queenmother. She has continued to raise funds for the MKQMA’s projects since her return. International dignitaries such as Mrs. Theresa Kufuor, wife of Ghana’s president, John Kufuor and also UNDP Goodwill Ambassador from Japan, Ms. Misako Konno, have been made honorary queenmothers.
IV. CONCLUSION: POLICY IMPLICATIONS
HIV/AIDS has far-reaching and extensive social, political, economic, cultural, and security implications. For developing countries, challenges and goals for development are massively compounded and frustrated by HIV/AIDS. Ghana’s national policy responses articulate the necessity of formulating and mobilizing multisectoral participation in HIV/AIDS policies and programming. Ghana has recognized traditional leaders as a sector within the country and have proposed various means for the involvement of traditional leaders in the fight against HIV/AIDS.
Prevention and impact mitigation of HIV/AIDS in developing countries will require the complete mobilization of all productive resources, human and capital, in the fight against HIV/AIDS. As the case of Ghana shows, traditional leaders can play effective roles in this fight. Drawing upon the concepts of differently rooted legitimacies, shared legitimacy, social marketing, and AIDS competence, and the examples of a number of traditional leaders in Ghana, especially cases of the Asantehene, Okyenhene and the Manya Krobo Queenmothers, it has been argued that traditional leaders can and have served in various capacities in HIV prevention and impact mitigation. Acting as directors, intermediaries, advocates, and advisers, traditional leaders have contributed to social marketing campaigns which ultimately contribute to the development of local AIDS competence. By lending their authority and credibility to HIV prevention, awareness, and support, traditional leaders contribute to the creation of positive and informed communities. Traditional leaders who have local credibility are thus an example of a grassroots governance community intervention best-practices model. Thus, faced with the limited capacity of the African post-colonial (or “modern”) government, the pooling and collaboration of differently rooted legitimacies (traditional leaders and the post-colonial state) produces more effective responses to HIV/AIDS. Traditional leaders’ involvement in Ghana has become part of what Prof. Sakyi Amoa, director of the Ghana AIDS Commission, has advocated as the “social vaccine” (“Ghana AIDS Treatment Plan Begins in January,” [on-line], 30 November 2003). The effectiveness of traditional leaders as part of the social vaccine against HIV/AIDS needs further investigation, especially as Ghana may offer an additional AIDS-fighting strategy to other countries in which divided legitimacy exists.
ACKNOWLEDGMENTS
This research was funded by a major grant from the International Development Research Centre (IDRC) of Ottawa, Canada, to the Traditional Authority Applied Research Network (TAARN), whose project leader is Professor Don Ray, as well as a grant to Don Ray from the Social Sciences and Humanities Research Council of Canada (SSHRCC). We would like to gratefully acknowledge the following individuals for their contributions to this research and for their work in HIV/AIDS in Ghana. From the Ghana AIDS Commission, we would like to thank Prof. Sakyi Amoa, executive director and Dr. Sylvie Anie, director of resources and policy implementation. We would also like to acknowledge the contributions of the Manya Krobo konor, Nene Sakite II, and the deputy paramount queenmother, Manye Natekie, to the research and to HIV/AIDS efforts in Manya Krobo. The work and contributions of the Asantehene, Otumfuo Osei Tutu II, and the Okyenhene, Osagyefuo Amotia Ofori Panin in HIV/AIDS prevention, education, and impact mitigation serve as important examples of how traditional leaders and others in positions of authority can create positive and dynamic environments that support and foster social change and development. We would also like to acknowledge the support and work of the following governmental and nongovernmental organizations that conduct important research and support activities around HIV/AIDS in Ghana and globally: Family Health International, the Canadian International Development Agency, the Global AIDS Awareness Group of the University of Calgary, and AIDS Calgary. Don Ray received a Killam Resident Fellowship, which provided him with time to write up much of the material for this paper. We would like to express our thanks to all those who made this research possible.
GHANA AIDS COMMISSION HEADQUARTERS IN ACCRA. (PHOTO: DR. DON I. RAY.)
MANYE NARTEKIE, DEPUTY PARAMOUNT QUEENMOTHER OF MANYA KROBO AND PROJECT MANAGER OF THE MKQMA, STANDING IN FRONT OF CLOTH PRINTS MADE AS PART OF THE YOUNG WOMENS MKQMA’S PROJECT. (PHOTO: DR. DON I. RAY.)
ODUMASE-KROBO, GHANA, WEST AFRICA. (PHOTO: DR. DON I. RAY.)
QUEENMOTHERS OF THE MANYA KROBO QUEENMOTHERS ASSOCIATION. (PHOTO: DR. DON I. RAY.)
Notes
1 The book Grassroots Governance, in particular the chapters by Ray, Owusu-Sarpong, Thornton, and Zips, explores these and related concepts. Don Ray appreciates discussions and debates with Werner Zips, Christiane and Albert Owusu-Sarpong, Robert Thornton, Tim Quinlan, Keshav Sharma, M. Molomo, Kwame Arhin, Jean-Michel Labatut, and Sherri Brown, which have led to the enhancement of the “divided legitimacy” school by also using the concepts of “shared legitimacy,” and “pooled legitimacy.” See also Ray (1996; 1997) for earlier discussions of divided legitimacy contributing to development. Ray (1997) can be accessed at the TAARN website (http://www.ucalgary.ca/~taarn/).
2 The Okyenhene and the Asantehene are two kings who are outstanding leaders in Africa’s fight against HIV/AIDS.
3 Interestingly, one of the meanings of “allegiance” in the Oxford Illustrated Dictionary is “Duty of subject to sovereign or government.”
4 The term “traditional area” refers to a post-colonial state recognized in a geographically defined area and which is usually headed by a paramount chief (otherwise called a king) who is automatically the president of the traditional council of the traditional area. There are some traditional areas in which the presidency rotates between three or four divisional chiefs. See Ray (2003a) for further details.
5 Others were addressing the needs of men. For example, the konor (king) of Manya Krobo wanted to create a program for men who drove long-distance truck routes as they were identified as another high-risk target group for HIV infection and transmission.
6 IDRC and TAARN have not provided funding to the Manya Krobo Queenmothers Association. Rather the IDRC funding of TAARN’s research created a research linkage between TAARN and the Manya Krobo Queenmothers Association. TAARN members at the University of Calgary gave presentations on the research to Canadians who in turn have partnered with the MKQMA for development and funding purposes.
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